Self-Employment Tax Deduction for Modified Adjusted Gross Income (MAGI) Medical Assistance (MA), PMA19662312 (Published November 1, 2019)
Changes to the Treatment of Income and Deductions for Modified Adjusted Gross Income (MAGI) Medical Assistance (MA), PMA19301312 (Published March 1, 2019)
Notice of End of Coverage for the Postpartum Period, PMN19268312 (Published February 7, 2019)
"S" Corporation Income, PMA18469312 (Revised June 14, 2018)
Minimum Essential Coverage (MEC) Reporting to the Internal Revenue Service (IRS) and Individuals, OPS161201 (Published December 6, 2016)
Medical Assistance Program Changes due to the Introduction of Enhanced Federal Medical Assistance Percentage, OPS160305 (Published March 10, 2016)
Effective January 1, 2014, the Affordable Care Act (ACA) changed Medical Assistance (MA) rules in Pennsylvania. Modified Adjusted Gross Income (MAGI) is the new income methodology used for determining MA eligibility for children through age 18, parents (biological, adoptive or step), caretakers, pregnant women and adults ages 19-64.
MA rules have not changed for individuals whose eligibility is determined on the basis other than MAGI:
Individuals for whom income determinations are not required, such as individuals receiving Supplemental Security Income (SSI), federal foster care or adoption assistance recipients or recipients of Breast and Cervical Cancer Prevention and Treatment (BCCPT) services.
Individuals whose eligibility is based on being 65 or older, disabled or blind.
Individuals evaluated for Medically Needy Only (MNO).
Individuals evaluated for Long Term Care (LTC) facility services or Home and Community Based Services (HCBS).
Individuals eligible for Medicare cost sharing.
Individuals evaluated for General Assistance (GA) related MA.
The MA category MG is used to identify the majority of MAGI-related budget groups, (See Chapter 305, Appendix E: Medical Assistance Cascade Table). Individuals receiving category MG will be assigned a program status code based on the coverage group.
MAGI categories and program status codes:
MG00 - Pregnant and postpartum women and children (under age 1) with income at or below 215 percent of the Federal Poverty Income Guideline (FPIG), children (ages 1-5) with income at or below 157 percent of the FPIG, children (ages 6-18) with income at or below 100 percent of the FPIG, and children (ages 6-18) with income between 100 and 133 percent of the FPIG with Minimum Essential Coverage (MEC) health insurance (See Chapter 312.14 Children Ages 6-18)
MG18 - Pregnant and postpartum women and children under 1 who are eligible for extended medical coverage despite an increase in income over 215 percent of the FPIG. Children under 4 enrolled in certain Cash or MA categories who become ineligible due to excess income, whereabouts unknown, failure to provide information, or failure to keep an appointment during their 12-month continuous eligibility period.
MG19 - Children age 6-18 with income between 100 percent and 133 percent of the FPIG without Minimum Essential Coverage (MEC) health insurance (See Chapter 312.14 Children Ages 6-18).
MG27 - Individuals with income at or below 33 percent of the FPIG. Individuals could be parents/caretakers and children ages 0-17, or children age 18, if they are a full-time secondary or vocational student.
MG23 - Individuals eligible for Transitional Medical Assistance (TMA) due to an increase in alimony/spousal support. Individuals with alimony that is not countable for MAGI MA are NOT eligible for Transitional Medical Assistance (TMA) in the MG 23 category.
MG38 - Individuals ages 21-64 who are temporarily disabled and incarcerated in a State Correctional Institution. See Chapter 392.2 for more information.
MG39 - Individuals ages 21-64 who are temporarily disabled and incarcerated in a county prison. See Chapter 392.2 for more information.
MG71 - Individuals eligible for Transitional Medical Assistance (TMA) due to an increase in earned income.
MG90 - Individuals ages 19-64 with a permanent disability (MRT or SSA verified) with income at or below 102 percent of the FPIG and are not eligible for Medicare or individuals ages 19-20 with income at or below the Enhanced Medically Needy Only (MNO) limit and are not eligible for Medicare. (See Appendix A for Enhanced MNO income limits). If an individual has refused or withdrawn from Medicare, they should still be considered as entitled and receiving Medicare. Individuals who report a pregnancy while receiving MG 90 will remain in MG 90 until the end of their postpartum period or next renewal, whichever comes first.
MG91 - Individuals ages 19-64, including individuals with a permanent disability that is not verified by SSA or MRT, with income at or below 133 percent of the FPIG and are not eligible for Medicare. If an individual has refused or withdrawn from Medicare, they should still be considered as entitled and receiving Medicare. Individuals who report a pregnancy while receiving MG 91 will remain in MG 91 until the end of their postpartum period or next renewal, whichever comes first.
MG99 - Individuals who are suspended from MA for less than 2 years due to incarceration.
PC40 - Former foster care recipients.
PSF15 - Individuals with income at or below 215 percent of the FPIG who only receive Family Planning Services (FPS) and were first evaluated for MA.
PSF14 - Individuals with income at or below 215 percent of the FPIG who only receive FPS and were not reviewed for MA because they claimed "good cause" or were under 21 and only wanted to be reviewed for FPS or are under 21 and are over income for PSF15 using MAGI net income.
MAGI-related budget groups are
built using the following target types:
NOTE: MG91 (except MG91P), PC40, PSF15 and PSF14 are built with no target types.
The CAO must decide who can get MA using the rules in this chapter and the following chapters:
Medical Assistance Eligibility Handbooks
NOTE: The client must report changes in gross monthly earned income of more than $100 and of gross monthly unearned income of more than $50. All other changes, including new sources of income, must continue to be reported.
Supplemental Handbook
Chapter 910 Overpayment Recovery.
PO17680910 MA Overpayment and Family Planning Services Sept 4,2015
Supplemental Handbook Chapter 950 Enumeration
A pregnant woman or a qualified child up to age 1 can get MAGI-related MA if household income is equal to or less than 215 percent of the Federal Poverty Income Guideline (FPIG) for the household size (See Appendix A).
The pregnant woman, once approved, continues to be eligible for MA coverage through the end of 12th month when the 12-month postpartum period ends, regardless of her income or a change in circumstances. (See Chapter 338.42)
The newborn whose mother was getting MA or CHIP at the time of birth can get MA coverage up to age one, regardless of the parents’ income, per the Children's Health Insurance Program Reauthorization Act of 2009 (CHIPRA).
Children under one who were not born to a mother on MA or CHIP at the time of birth are eligible for a 12-month continuous eligibility period (See Section 312.131).
NOTE: If the CAO did not know about the pregnancy and learns that cash or MA benefits were closed during the pregnancy, it must approve MA coverage from the date of the closing through the last day of the month in which the 12-month postpartum period ends.
Newborns and pregnant/postpartum individuals can only be closed during their periods of continuous eligibility for the following reasons:
Voluntary Withdrawal
Permanent Move Out of State
Death of the Individual
If the CAO determines that the opening of benefits was incorrect due to fraud or abuse or agency error.
When a provider or other outside source asks for MA benefits for a child under age one, the CAO must review the family’s case record to see if Cash or MA or CHIP benefits were open for the mother at any time during the pregnancy. If so, the CAO must authorize MA benefits for the child from the date of birth until the first birthday.
A qualified child age 1-5 can receive MAGI-related MA if household income is equal to or less than 157 percent of the FPIG for the household size (See Appendix A).
312.131 Continuous Eligibility for Children under Age 4
Children under age 4 eligible for Cash or MA at application or renewal remain eligible for MA coverage in MG 18 C until their next 12-month renewal or until the child reaches age 4, regardless of changes that affect their MA eligibility. Children in certain MA categories are not eligible for continuous eligibility (See Appendix H).
CAOs must not change the MA renewal date for budgets that qualify for continuous eligibility while aligning other budgets.
The CAO must close children under 4 if:
The child turns age 4. AGE 053 alert will be generated to identify children in MG 18 C who turn 4.
The child is not eligible for MA at their renewal.
NOTE: If a child under 4 is ineligible for MA at renewal, the CAO must close the child under four in Reapplication mode during or after the renewal month. The CAO should review the case to ensure that the child has received a full 12 months of MA coverage prior to closing the child’s MA budget. The child will be referred to CHIP or the FFM in accordance with existing referral rules if the child is ineligible for MA at renewal.
The child is deceased.
The child moves out of state.
The child is institutionalized.
A voluntary withdrawal request is received for MA.
The CAO determines that the child’s MA was opened in error.
Citizenship or satisfactory immigration status is not verified following a Reasonable Opportunity Period (ROP)
The CAO must not close children under 4 for:
Exceeding income limits.
Whereabouts unknown.
Failure to provide information.
Failure to keep an appointment.
When a CAO processes an inter-county transfer for a child who was open for an MA category eligible for Continuous Eligibility and the child is determined ineligible for MA in a new county due to a change in circumstances, the CAO will open the child in MG 18 C with the original renewal date.
A qualified child age 6-18 can receive MAGI-related MA if household income is equal to or less than 133 percent of the FPIG for the household size (See Appendix A).
If a child age 6-18 has income under 100 percent of the FPIG for the household size or a child (ages 6-18) with income between 100 and 133 percent of the FPIG with Minimum Essential Coverage (MEC) health insurance, MG00 is assigned.
If the child age 6-18 has income between 100 percent and 133 percent of the FPIG without Minimum Essential Coverage (MEC) health insurance, MG19 is assigned.
Health insurance may be reported and available to the CAO on applications, renewals, through client reported changes, or Third-Party Liability (TPL) screens in the case record, etc. If the reported health insurance is considered MEC (see MEC Desk Guide for information about what insurance is MEC), the CAO will check the “Minimum Essential Coverage?” box on the Individual Attributes screen when information is available that shows a child, age 18 and under, has MEC health insurance. It is important to check this box for all applying children age 18 and under due to changes to category of eligibility that may occur.
If health insurance coverage is reported on a new application, on a renewal, or through client reported changes, the CAO will update the MEC indicator on the Individual Attributes screen accordingly. The CAO will not require that the insurance question be answered on the application. The CAO will follow the existing verification policy in Chapter 378.3 to verify health insurance.
NOTE: MA should not be delayed or terminated for an individual whose responsible relative fails to cooperate in identifying and verifying TPL information.
Health insurance may also be systematically updated by TPL batch processes. Any time the CAO takes action on a case with an open MG 19 category, the CAO will review the TPL screens and ensure that the “Minimum Essential Coverage?” box is checked if the TPL screens list MEC insurance.
COMPASS Real-Time Eligibility:
Children age 6-18 with household income between 100 and 133 percent FPL with any type of health insurance reported on the application are authorized in the MG 00 category. The reported health insurance and the MEC check box will not be populated in eCIS. The next time the CAO takes action on the case they must update the MEC indicator on the Individual Attributes screen and review TPL information.
For a child age 18, student status will impact the program status code that is assigned. An 18-year old can be eligible as MG27 if they meet all eligibility criteria and he or she has the following student status:
Full-time secondary student, or
Full-time vocational/technical school student
If the 18-year old does not have the above student status, MG00 or MG19 can be assigned if all other eligibility criteria are met.
A parent (biological, adoptive or step) or caretaker can receive MAGI-related MA. The following criteria must be met:
Have care and control of a child age 0-17 or age 18 and a full-time secondary or vocational/ technical school (vo-tech) student.
Have household income equal to or less than 33 percent of the FPIG (See Appendix A).
NOTE: Individuals other than parents with care and control of a child in the MAGI-related household can be caretakers, if the parent is not living in the household. For MAGI-related MA, an individual does not need to be related to the child to be a specified relative in the parent/caretaker category. Caretakers are individuals age 19 or older.
NOTE: If no parents are taking care and control of the child in a household, only one non-parent caretaker is a valid target. If multiple non-parent caretakers are present in the household, only one caretaker will be selected in order of age, oldest to youngest.
Individuals age 19-64 can receive MAGI-related MA if household income is equal to or less than 133 percent of the FPIG for the household size (See Appendix A).
If an individual age 19-20 has income at or below the Enhanced MNO limit (See Appendix A), the individual will be assigned category/program status code/target type of MG90N.
If an individual 19-64 has a permanent disability (SSA or MRT certified), has income at or below 102 percent of the FPIG, (See Appendix A) and is not entitled to Medicare, the individual will be assigned category/program status code/target type of MG90D.
All other individuals 19-64 will be assigned category/program status code MG91.
If a woman between the ages of 19-64 is receiving MG90 or MG91 and reports a pregnancy, she will be opened in MG90P or MG91P respectively, and she will remain in MG90P or MG91P until the end of her postpartum period or until the renewal is processed, whichever is sooner.
Individuals who report a disability will be evaluated for non-MAGI MA and MAGI MA.
If the individual’s disability is not verified by SSA or MRT, the CAO will review for MAGI eligibility first. The CAO will review for non-MAGI MA if the individual is not eligible for MAGI MA, or if the individual is determined disabled by SSA or MRT.
If the individual’s disability is verified by SSA or MRT, the CAO will review for non-MAGI MA prior to authorizing MG90D or MG91.
NOTE: For MG90 and MG91, the individual must not be eligible for or receiving Medicare.
See Chapter 338, Medical Assistance Benefits for information about MA benefits.
The CAO does not consider resources when deciding an individual's eligibility in a MAGI-related MA category.
Updated September 19, 2023, Replacing September 20, 2022